Exploring psychedelic use in athletes and their attitudes toward psilocybin-assisted therapy in concussion recovery

Background: Psychedelics are receiving growing interest among clinical researchers for their effects on mood and cognition. Psilocybin is one of the most widely studied classic psychedelics which has shown good safety and clinical benefit for major depression and substance use disorders. Athletes frequently sustain concussions and often experience myriad symptoms, including cognitive and mood issues, which can persist for weeks or months in 10%–30% of athletes. Psilocybin may be a potential symptom management option for athletes with persisting concussion symptoms. Objectives: This study sought to summarize athlete psychedelic use, among other substances, and to examine the willingness of the sports community to engage in or support psilocybin-assisted therapy (PAT) for concussion recovery and management of persisting concussion symptoms. Methods: In total, 175 (n = 85 athletes; n = 90 staff) respondents completed an online survey distributed in Canada and the United States which queried sport involvement and demographics, substance use, concussion history, and knowledge and willingness about psilocybin. The reporting of this study conforms to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) statement. Design: Substance use rates were summarized across athletes and team staff members and a path analysis was used for each sample to identify predictors of willingness to use PAT (athletes) or support PAT (staff) for concussion recovery. Participants were also asked to identify perceived barriers to the implementation of PAT for sports-related concussions, and to indicate their overall willingness. Results: Psychedelics were the third most used substance in the past year among athletes (35.8%) while regular psychedelic use was quite low in athletes (7.5%). A path analysis conducted in RStudio found that attitudes toward psilocybin and knowledge of psilocybin were significant predictors for both athletes and staff members of their willingness to use or support PAT for concussion recovery. Athletes reported likely engaging in PAT (61.2%) and staff (71.1%) reported that they would support their athletes using PAT. Conclusion: The results of this study suggest that the sports community may be receptive to PAT and athletes would be willing to engage in it for concussion recovery and/or the management of persisting post-concussion symptoms (PPCS). Future research should examine the effects of psilocybin for PPCS to inform whether there is any impact while addressing concerns regarding long-term effects of psilocybin use.


Background
Sports-related concussions (SRC) are a form of mild traumatic brain injury (mTBI) that occurs while engaging in sports. 1 In the United States, roughly 3.8 million sports-related brain injuries occur annually 2 while in Canada, available data from 2020 to 2021 identified almost 2000 emergency department visits for sports-related brain injuries. 3The conceptual definition of SRC according to the Concussion in Sport Group (CISG) was updated at the Amsterdam 2022 International Consensus Statement on Concussion.This improved definition involves the following major points: (1) force is transmitted to the brain via a blow to the head, neck, or body through sport or sport-related activities; (2)  the resulting injury to the brain occurs through a neurotransmitter and metabolic cascade; (3)  symptoms can onset rapidly or overtime and typically resolve within days but may persist; (4) injury is typically functional rather than structural and will not be seen on standard structural neuroimaging studies; and (5) clinical presentation is broad and diverse and may or may not include loss of consciousness. 4 Therefore, SRCs can be understood as a type of mTBI which are a serious injury that can significantly affeet quality of life.6][7][8] Common psychological symptoms include mood dysregulation (i.e.anxiety, depression, irritability) and cognitive impairments in executive function, memory, attention, and concentration. 6,9,10Physiological symptoms include headache, fatigue, and light and noise sensitivity. 6Both psychological and physiological symptoms can be greatly debilitating in athletes across multiple areas of life (i.e.interpersonal, academic, work, leisure, sport) and can prolong the time before returning to work, school, and/or sport. 5Currently, the recommended management of symptoms from the Canadian Guideline on Concussion in Sport includes cognitive and physical rest 11 which may be supplemented by nonsteroidal anti-inflammatory drugs in the acute phase of concussion recovery. 12This rest period is followed by a step-wise progression to reintroduce regular activities beginning with light cognitive load until full return to activity is achieved. 11However, despite this approach being the primary treatment recommendation, this approach does not work for every athlete, and because up to 30% may endure PPCS, an individualized treatment approach must be implemented.Improved concussion rehabilitation approaches and managing PPCS are among the most requested areas of research from patients, clinicians, and researchers. 4,13herefore, the current study explores the willingness of the sports community to engage in (as an athlete) or support (as a staff member) psilocybin-assisted therapy (PAT) for concussion recovery and PPCS in athletes.This study aims to contribute to the ongoing discourse surrounding concussion rehabilitation and offer insights into novel avenues such as psychedelic therapy for managing PPCS.

The role of psilocybin
Psilocybin is a classic psychedelic that is metabolized into psilocin on ingestion. 14Research suggests that activity at the serotonin 2A receptor (5-HT 2A R) is a key mechanism of the psychedelic effects of psilocybin. 150][21][22] A recent scoping review summarized the effects of psilocybin on cognitive functioning, finding temporally variable effects, suggesting that although psilocybin may lead to acute cognitive impairment, it does not impair cognitive functioning long-term. 234][25] This safety profile is especially important when considering use in clinical populations with a brain injury.
Although psilocybin has not been formally investigated in people with SRC, we hypothesize that psilocybin may benefit those with sports concussion and persisting symptoms through three primary mechanisms: [32] The current study While current research highlights a theoretical proof of concept in examining PAT for SRC and PPCS, 23,26,27,29,30,31,33 it is unclear whether the sports community may be receptive to the use of psilocybin in concussion recovery.Data from a U.S. national survey found that adults aged 26-34 were more likely to engage in psilocybin use compared to adults 18-25 years old, and respondents who completed high school and/or college were more likely to report having used psilocybin. 34In a sample of psychotherapists, attitudes and knowledge of psilocybin were positively correlated with willingness to recommend PAT to patients. 35Similarly, Melnikov et al. 36 found that attitudes toward medical cannabis significantly influenced the likelihood that healthcare professionals would recommend medical cannabis as a treatment to their patients.Thus, variables such as age, education, attitudes, and knowledge emerge as important variables to examine in one's willingness to engage in or support PAT for concussion recovery.Therefore, this study was designed to gather relevant information to provide an understanding of interest and concerns from athletes, coaches, and other sports staff regarding the therapeutic use of psilocybin.
This study used a descriptive, open, online survey approach to address the following three objectives.The first objective is to provide an estimate of current rates of general psychedelic use among journals.sagepub.com/home/tppTherapeuTic advances in psychopharmacology athletes in Canada and the United States across levels of competition and the motivations for use.The second objective is to summarize the sports community's current attitudes and beliefs specifically about psilocybin and its therapeutic use for concussion recovery and managing persistent concussion symptoms.The third objective is to report the willingness of athletes to engage in psilocybin for the treatment of concussion and persistent symptoms and the level of support from sports team personnel for athletes interested in this treatment option.
Given the lack of research on this topic, we will examine current psychedelic use rates among athletes and motivations for use in athletes using an exploratory approach.Based on previous literature, it is hypothesized that greater age, education, knowledge, and attitudes will predict willingness to engage in or support PAT, and we examine concussion history as an exploratory variable in the athlete sample.

Methodology
The reporting of this study conforms to the CHERRIES statement 37 Survey features.All respondents were required to complete a Captcha verification (Completely Automated Public Turing Test to tell Computers and Humans Apart) to ensure unique visitors and human participants, prior to beginning the informed consent process. 37ing skip logic, questions were only presented to respondents when they met criteria for that question (e.g. by selecting "athlete," further questions on concussion history were revealed), to prioritize response efficiency.Respondents were requested to complete all questions but were not required to do so to submit their survey response.Due to the anonymized nature of the survey, we did use cookies, track IP addresses, or require respondents to log in to access the survey.
Participants.For this study, the population of interest included athletes and individuals involved as staff members to a sport team at any capacity (i.e.coach, trainer, or physical therapist) and at any level of competition (i.e.recreational, club, collegiate, etc.).Inclusion criteria were: (1) current involvement in a sports team as an athlete or a team personnel; (2) 18 years old or older; and (3) currently living within Canada and the United States.This study involved the completion of a three-part online survey.Exclusion criteria were thus: (1) not involved in sports; (2) under the age of 18 years old; and (3) currently living outside of Canada and the United States.
Survey section 1: demographics and clinical information.Key demographic information was collected including age, gender, race/ethnicity, country, sportsmanship level, sport(s) currently engaged in, and role (athlete or team personnel).The Ten-Item Personality Inventory 38 was used to examine the relationship between Big Five personality traits and the primary study variables.Finally, concussion history was collected from athletes which included questions about history of concussion, diagnosis, symptoms experienced, and what symptoms, if any, persisted after returning to sport.

Survey section 2: substance use information.
Information was collected from athletes pertaining to history of and current psychedelic use in addition to other drugs/alcohol.Questions included history and current use, psychedelic(s) of choice, method of intake, and motivations for use (mood enhancement, cognitive enhancement, pain management, relaxation, coping, etc.).

Survey section 3: attitudes and beliefs toward psilocybin.
Information was collected from athletes and sports team personnel regarding attitudes and beliefs toward psilocybin and willingness to incorporate it in PPCS recovery.Both the team personnel group and athlete group were asked about World Anti-Doping Agency regulation of psilocybin, attitudes toward psilocybin, knowledge of psilocybin, beliefs about addictive properties, perceived benefit of research on the topic, interest in learning more about psilocybin for medical use, and barriers to the implementation of PAT for concussion recovery in athletes.Athletes were queried on their willingness to use PAT for concussion recovery while staff were queried on their willingness to support athletes using PAT.Questions were ranked using a 7-point Likert scale.The full survey can be found in Supplemental Materials.
Sampling methods.Our sample was recruited using a variety of methods to acquire a diverse sample base.These methods included distribution of study flyers online and via social media pages specific to sports and athletes, such as Reddit forums frequented by sport participants, distribution of study information to university and college athletic departments, and word of mouth snowball sampling among athletes and training staff.Respondents were entered to win one of four gift cards following completion of the survey.E-mail addresses requested for entering the raffle were acquired through a redirected survey to separate addresses from survey responses and were deleted after the raffle draw was completed.

Statistical analyses
Descriptive statistics (i.e.mean, standard deviation, skew, kurtosis) were calculated for the entire sample as well as each category (athletes/team personnel).Data were examined for outliers using the Mahalanobis distance.To limit accidental omission of responses, we employed a request response validation if a question was not answered, with the option to skip the question if participants chose not to answer.
Two path analyses were conducted in RStudio version 2021.09.0 to test two proposed models (one for athletes and one for staff) developed based on prior literature and exploratory variables such as concussion history (for the athlete model only).The proposed models (see Supplemental Materials) were developed to test the effect of demographic variables (age and education), personality trait openness (measured through the Ten-Item-Personality Inventory [TIPI]), knowledge of psilocybin, attitudes toward psilocybin, past psychedelic use experience, and concussion history (for the athlete model) on willingness to engage in or support PAT for persisting concussion symptoms.All other data analysis was conducted in SPSS Version 27 (IBM Corp. Released 2020.IBM SPSS Statistics for Windows Version 27.0 Armonk, NY: IBM Corp).

Overall respondent characteristics
At the end of the data collection period (June 1, 2023), our sample consisted of 175 participants, out of 235 initiated surveys (74% completion rate; Table 1), a majority of which were male (67.4%),Caucasian (59.4%), and from the United States (57.7%) between the ages of 18 and 76 years old, with a mean (M) age of 30.52 years (SD = 9.02).Demographic information are described separately for the athlete and staff samples below and demographics for the full sample can be found in Table 1.

Staff demographics
Our staff sample consisted of 90 staff members (M = 32.21,SD = 8.07) who primarily identified as male (65.6%) from the United States (63.3%).Staff members were most frequently coaches (53.3%) at the collegiate level (38.2%) and the most common sport they coached was softball (22.2%).
Athletes.Most athletes indicated using drugs at least once in their life (62.4%)while two athletes selected to not disclose their drug use history.Of those who reported using drugs at some point in their life (n = 53), all reported using drugs or alcohol within the past year and 56.5% of athletes indicated using drugs or alcohol regularly.The most commonly used substances in the past year were alcohol (90.6%), cannabis (43.4%), and psychedelics (35.8%) while the most commonly used substances regularly (⩾2 times per week) journals.sagepub.com/home/tppwere alcohol (50.9%), cannabis (18.9%), and tobacco (15.1%).With regard to the first objective of this study, to provide an estimate of psychedelic use among athletes, we found that 22.4% of athletes reported using psychedelics in their lifetime.Among those, 35.8% reported using psychedelics in the past year, and 7.5% reported using psychedelics regularly.The most common psychedelic used among athletes was psilocybin (64.3%).The primary motivations for using psychedelic among athletes was personal improvement or general well-being (16.4%) and mood enhancement (12.3%).As previously mentioned, the majority of our athlete sample competes at recreational and collegiate levels.Therefore, these rates of psychedelic use may not apply to athlete populations with more rigid substance use restrictions.

TherapeuTic advances in psychopharmacology
Psychedelic use among athletes and staff.All respondents who reported using psychedelics within the past year (34.5%) were asked about their patterns and reasons of use.Our participants primarily indicated using psychedelics a few times a year with the most common psychedelic used being psilocybin (59.6%).The reasons for use were most often for personal improvement (14.5%) and mood enhancement (13.6%).Participants reported using psilocybin for a number of health-related conditions including anxiety (n = 16), depression (n = 16), and trauma-related reasons (n = 9).Participants generally reported improvements in these areas.

Concussion history frequency
Our survey found that 56% (n = 48) of our athletes had experienced at least one concussion.Of those athletes, 83.3% reported receiving a medical diagnosis of a concussion with 90% of these concussions being diagnosed by a physician.The most frequently endorsed concussion symptoms were headache (13.4%), nausea (10.9%), and fatigue (10.5%).Athletes reported myriad symptoms which could be captured under the umbrella term of "cognitive symptoms."These cognitive symptoms include feeling in a fog, feeling slowed down, memory complaints, and difficulties with concentration and attention.A total of 29.3% of reported symptoms among athletes fell within this umbrella of "cognitive" symptoms.Mood symptoms accounted for 6.1% of those experienced by athletes.
In our sample of athletes, persisting concussion symptoms occurred in 83% (n = 40) of those who reported a history of concussion.Persisting symptoms lack a strong definition given poor consensus among the field.However, we asked athletes which symptoms persisted after they were cleared to reengage in sports performance.The most frequently reported persisting symptoms included headache (21.7%), nausea (10.8%), fatigue (10.8%), and sleep difficulties (10.8%).Again, cognitive symptoms were highly reported with 21.7% of persisting symptoms being cognitive while mood symptoms were less likely to persist (4.8%).

Attitudes toward psilocybin
Athlete attitudes.Just over half of the athlete sample was familiar to some degree with psilocybin (56.5%) and 38.8% had favorable attitudes toward psilocybin while 40% had some level of knowledge of psilocybin.Most important, 67.1% of athletes believe that psilocybin was addictive or had the ability to be abused.However, over half of athletes were interested in learning more about PAT for mental health, concussion recovery, and other medical concerns (55.3%) and felt that there was benefit in examining the medical use of psilocybin (57.6%).
Staff attitudes.Just over half of team staff were familiar with psilocybin (54.4%), had favorable attitudes toward psilocybin (52.2%), and were knowledgeable of psilocybin (54.4%).Over half of the team staff felt that psilocybin was addictive or likely to be abused (57.8%).Two-thirds of staff felt that there was benefit in examining the medical uses of psilocybin (66.7%) and the majority of staff were interested in learning more about the medical uses of psilocybin (76.7%).
PAT willingness Athlete willingness.Athletes were asked whether they would be willing to engage in PAT for PPCS if they were experiencing it themselves and research indicated that PAT was beneficial for this purpose.About a quarter (23.5%) of athletes indicated that they would be "very likely" to engage in PAT.In addition, 22.4% and 15.3% indicated that they would be "likely" and "somewhat likely," respectively, to engage in PAT for this purpose (Figure 1(d)).Finally, 25.9% of athletes indicated that they would be "very unlikely," "unlikely," or "somewhat unlikely" to engage in PAT for concussion recovery.
Staff willingness.Sports team staff were asked whether they would be willing to support their athlete(s) dealing with PPCS in using PAT if research indicated that it was beneficial, with 25.6% of staff indicating that they would "likely" support this, while 21.1% indicated they would be "somewhat likely," and 24.4% "very likely."Another 15.6% of sports team staff indicated that they would be "very unlikely," "unlikely," or "somewhat unlikely" to support PAT for concussion recovery (Figure 1(e)).

Perceived barriers to PAT for concussion recovery
We queried athletes and staff regarding significant barriers to implementing PAT for concussion recovery in athletes.A recurrent theme across athletes and staff were concerns regarding the long-term effects of psilocybin therapy with 24.0% of athletes and 24.7% of staff indicating this as a concern.Athletes highlighted the stigma from their coaches or other team staff (18.3%) as another prominent concern whereas staff believed access to psilocybin treatment (19.2%) to be a significant barrier.

Path analysis
Correlations.Pearson correlations were conducted with the path variables of interest to examine any significant relationships, direction of relationships, and any especially strong relationships (i.e.multicollinearity).This was especially necessary for exploratory variables.Correlation coefficients revealed that willingness to use PAT among athletes was significantly and positively correlated with psilocybin attitudes (r = 0.57, p < 0.001) and psilocybin knowledge (r = 0.55, p < 0.001).Willingness to support PAT as a staff member was also significantly and positively correlated with psilocybin attitudes (r = 0.48, p < 0.001) and psilocybin knowledge (r = 0.49, p < 0.001).All other correlations were not statistically significant, see Supplemental Materials for full correlation results.

Discussion
Psychedelic use by athletes has been scarcely documented, and to our knowledge, this is the most comprehensive and recent examination of psychedelic use in Canadian and American athletes.This is also the first survey to examine athlete   willingness to engage in PAT for concussion recovery and persisting concussion symptoms and staff willingness to support this treatment in athletes.Despite researchers discussing the clinical utility of psilocybin for athlete mental health, particularly in those with a history of concussion, 39 research on this population has not been yet published.The use of psychedelics for mental health concerns in former athletes is being discussed in mainstream news with popular journals.sagepub.com/home/tpp TherapeuTic advances in psychopharmacology athletes as former National Hockey League players Daniel Carcillo and Riley Cote coming forward to discuss their experiences with psilocybin. 40These anecdotal experiences suggest the examination of psilocybin use in concussion recovery and persisting symptom management is a timely and worthwhile endeavor, and this study may begin to pave way for the examination of psilocybin for acquired brain injury.Most important, the implementation of psilocybin for the management of PPCS would strongly depend on the willingness of the population to engage in this approach, thus this study represents an important early step prior to the commencement of clinical trials.
We found some evidence of current psychedelic use among athletes across levels of competition and that this sample of athletes favors psilocybin.
Our sample primarily consisted of recreational and collegiate athletes with limited professional athlete respondents.Compared to a previous study in American collegiate athletes, the only other survey to discuss athlete psychedelic use, we identified higher rates of psychedelic use in our sample. 41his may in part be due to the rising discussion of psychedelics among researchers and mainstream media.Moreover, growing discourse among former elite athletes may also fuel the increase of psychedelic use among our sample of athletes.In contrast to prior literature, the primary reasons athletes in our sample used psychedelics were for personal improvement and mood enhancement, compared to recreational or social reasons. 41ile our sample endorsed primarily neutral attitudes toward psilocybin, respondents were somewhat familiar with psilocybin and knowledgeable about the medical uses of psilocybin according to self-identified knowledge and familiarity.However, given that these were self-reported, there is potential for biases affecting their ratings, and their responses may not be supported by accurate knowledge.Specifically, staff were more likely to be concerned about possible addictive properties of psilocybin or the potential misuse than athletes were, despite research largely refuting the addictive potential of classic psychedelics. 42Most important, both athletes and coaches were concerned about the long-term effects of using psilocybin.Last, most participants were interested in learning more about psilocybin's potential use in mental health management and believed that there is benefit in examining psilocybin's use in PPCS management.
Findings from this survey suggest that our athlete population may be receptive to PAT through concussion recovery and the management of PPCS even in the presence of generally neutral attitudes toward psilocybin.This openness suggests viability of clinical research with an athlete sample to examine effects of psilocybin in PPCS, specifically examining the effects on the cognitive and mood symptoms.Provided that nearly a quarter of our sample endorsed cognitive symptoms following their concussion and 6.1% endorsed mood dysfunction, it is worth examining whether psilocybin may offer relief for athletes who experience such symptoms.
While research with other clinical populations (i.e.treatment-resistant depression, cancerrelated distress, substance use disorders) suggest therapeutic benefits of psilocybin, it is unclear whether these outcomes would translate in patients with brain injury.Similarly, some research indicates cognitive improvement with psilocybin use or negligible cognitive outcomes, but many studies which examine these cognitive outcomes have often used healthy participants rather than clinical populations, 23 limiting generalizability to TBI patients.Nonetheless, longterm outcomes of psilocybin represent a significant gap in the literature and were primary concerns of both athletes and staff regarding PAT in athletes with concussions.
As shown in both path analysis models, knowledge about psilocybin plays a significant role in willingness to use or support PAT.Specifically, higher levels of knowledge of psilocybin were associated with more positive attitudes toward psilocybin as well as greater willingness to use and support PAT.By identifying the impact of knowledge on willingness for both athletes and staff, recommendations can be made to improve knowledge dissemination to the sports community regarding psilocybin's safety and risks, current understanding regarding effects on athletic performance, and proposed effects that psilocybin might have in helping manage PPCS.This knowledge dissemination to and broad discussion with those that this treatment approach intends to benefit will be paramount.These findings also highlight the importance of taking a patient-oriented approach in future research which will involve athletes and staff in the research process.Their involvement will inform research design, development of treatment protocols, considerations for clinical implication, and concerns regarding sports performance and longterm effects.Thus, we can ensure that the sports community's voice is heard, and that the results be more efficiently applied to those in need.

Limitations
It is important to acknowledge certain limitations of the present study.First, the reliance on selfreported data invites the potential for response bias which could lead participants to respond inaccurately or in a socially desirable manner.
When surveying participants on drug use history and experiences, athletes may be hesitant to report their true experiences due to fears of potential consequences for drug use.It is also worth highlighting that bias may occur when participants rate their knowledge or proficiency in a subject.Thus, our measure of self-reported knowledge may not reflect accuracy in knowledge.Second, it is worth noting that athletes and sports team staff who responded to this survey may have done so out of personal interest or prior experience with psychedelics, potentially introducing a sample bias and inflated psychedelic use rates among athletes.We also recognize the difficulty in recruiting professional athletes, and that our sample lacked sufficient input from these athletes.Receptivity of PAT from such a population may differ based on rates of concussions among professional athletes, differences in training and intensity of play, and overall accessibility to psychedelics for a therapeutic purpose.Third, our survey found that almost half of our participants reported being drug naïve (i.e.never having used drugs or alcohol before).While we provided a brief description of psilocybin that avoided any bias ("The following questions focus on psilocybin which is a naturally occurring psychoactive substance found in Psilocybe mushrooms, also known recreationally as "magic mushrooms"), additional information may have been necessary to provide drug naïve participants with a more comprehensive base for what psilocybin is for the next questions.As such, neutral responses may have been a result of a limited understanding of what psilocybin is and/or the current state of psilocybin research.

Conclusion
The findings of this study suggest a high level of receptiveness in the sports community toward using and supporting PAT for concussion recovery given evidence that it is beneficial.These findings highlight the feasibility of collaborating with the sports community to examine this innovative therapeutic approach.Most important, knowledge about psilocybin emerges as a crucial factor influencing willingness, underscoring the importance of future initiatives that focus on fostering discourse between the scientific and sports communities.In bridging the gap between the communities and working in a collaborative approach, researchers can work to address key barriers identified by both athletes and staff members.Overall, this study indicates that conducting clinical research with athletes suffering from SRC and PPCS is a valuable research endeavor.

Figure 1 .
Figure 1.Violin plots displaying the density-based distribution of the Likert scale options for (a) attitudes toward psilocybin (all participants), (b) knowledge of psilocybin (all participants), (c) familiarity with psilocybin (all participants), (d) willingness to use PAT if you had a concussion (athletes only), and (e) willingness to support athletes using PAT for concussion recovery (staff only).

Table 1 .
Characteristics of participants.

Table 1 .
(Continued) 8journals.sagepub.com/home/tppa Participants could select more than one option.b Indicates questions responded to only by participants who reported using drugs or alcohol in the past year.c Indicates questions responded to only by athletes (n = 85).d Answered only by athletes with a history of concussion (n = 48).